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WelcomeFebruary 14
360 Degrees of Wound HealingWill begin at 2:00 p.m.
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Housekeeping Announcements
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RecordingThis live program (as well as all previous webinars) are also available via
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Request Your Certificates in the column entitled Live Teleconferences & Webinars. Certificates are available for 1 year after the program date.
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Please note: this course is considered a self study course by Ohio BENHA. Administrators are reminded that BENHA limits teleconference (home/self study) credits to a total of five (5.0) per renewal period.
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www.efohca.orgwww.efohca.org
Todays Format 90 minutes available for presentation & questions
Questions? During the presentation: you can type your questions
There will also be time for live questions & answers at the end of the presentation and the operator will explain that procedure
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Upcoming Programs:
Managing Reimbursement, RUGs and Key Reports February 14 15, ColumbusWinter Conference February 21 22, ColumbusTherapy Conference March 20, Columbus
Upcoming Webinars
February 28 - Reduce Unavoidable Hospital ReadmissionsMarch 13 - Does Your Toileting Program Have to Go?March 27 - Person Centered Care Plans that WorkMarch 28 - Ohio Nursing Home Licensure RulesApril 10 - The Who, What, When & How of Medication Administration
Todays SpeakerMary Jane Maloney, Chief, Clinical Operations, Northeast Surgical Wound Care (NESWC), is an Adult Health
Nurse Practitioner who graduated from Case Western Reserve University with a Masters in Nursing in 1998. Her clinical nursing experience is varied as she spent a full career in the United States Navy working with sailors, marines and their families nationally and overseas, transitioning to community health with the Cuyahoga County Board of Health as a health promotions coordinator. While pursuing her MSN Mary Jane was recruited for the Director of Nursing position of Metro Healths Emergency Department and Level I trauma center. A member of NESWCs practice since 2001 Mary Jane has transitioned from the top clinical production clinician to the APN primary clinical trainer and quality assurance manager. She developed the current electronic health record system for the practice and is working on a combined clinical and business intelligence project for long term care facilities. Additionally, Mary Jane has presented wound healing education at national and local conferences as well as university settings. Mary Jane attained her BSN from the University of Maryland, and an MS in Health Care Services from Salve Regina College, Newport, Rhode Island. She is board certified by the American Academy of Wound Management as a certified wound specialist. Mary Jane is very active with the Ohio Association of Advanced Practice Nurses as she has been the Past President (2009-10) and was re-elected for President for 2012. Finally, Mary Jane was presented with the American Academy Award for Nurse Practitioner Clinical Excellence in Ohio for 2011 this past June in Las Vegas, Nevada.
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Degrees of LTC
Wound Care
Mary Jane Maloney MSN CNP CWSNortheast Surgical Wound Care
Wound Care Program:You need a program or at least a plan!!!!
Policies ,Procedures, Protocols?
Standing Orders signed by Medical Director to implement protocol?
Designated Treatment Nurse?
Trained? How: OJT, formal?
Many Pros and Cons
Another lecture:
How to Become or Have a Super Treatment Nurse
What does WCC mean?
Does it expand scope of practice? NO
Can an WCC RN/LPN determine etiology? NO
Can an WCC RN/LPN write treatments orders without calling a provider? NO
Northeast Surgical Wound Care
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Optimization:Compromised Resident
Pre-Wounded
Tensile strength at 2 years: 80%
Offload as if wounded
If reopens on your watch, it is not present on admission
Diabetics
Keep serum glucose below 200
Keep HbAIC below 13
Good glycemic control
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Your Plan Continues Orientation of new nurses to your WC standards?
Inservices on wound care?
Skill competency at least yearly on NPWT or just plain wound care?
Wound Care
PrUs weekly assessments
Staging, Etiologies?
Can RN/LPN determine and MD signs off?
Keep track of all wounds and skin conditions
Wounds declining what do you do?
PCPs interested or knowledgable in WC?
Is formulary skimpy, OK or way too much?
Last Survey How did you do?
Any major change in policy, or staffing since last survey?
What worries you and your staff when your window opens?
Northeast Surgical Wound Care
Optimization: Compromised Resident
Malnutrition
Weight loss
Acute Inflammatory State
C- reactive Protein?
Prealbumin/Albumin?
How do you determine weight loss with edema?
Wound improving
Immobility
Say no to bedrest
Adherence to limitations
Document declination
Right equipment
Foam wedges instead of pillows
Suspension Boots instead of heel protectors
PR cushions on all non-ambulatory residents
APMs for all truncal wounds
Stamp out Penny
wise, Pound foolish
mentality
Northeast Surgical Wound Care
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Optimization:Compromised Resident
Pre-Wounded
Tensile strength at 2 years: 80%
Offload as if wounded
If reopens on your watch, it is not present on admission
Diabetics
Keep serum glucose below 200
Keep HbAIC below 13
Good glycemic control
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Wound Assessment
NOT ALL NURSES KNOW HOW TO DO ONE
Northeast Surgical Wound Care
Wound Measurements Length - widest Width - widest Depth deepest
Any skin disruption is given a depth of 0.1cm so volume may be calculated Eschar is a skin disruption
Blisters and sDTI are given depth of zero as epidermis is lifted, not open.
Do not use plastic circumference tools. inaccurate Help your nurses w/ presbyopia:
use paper measures. Average age of nurse (USA):
46.8 Only 8% are
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Wound Exudate
Characteristics Serous clear
Serosanguinous clear/bloody
Bloody
Purulent Liquification - good
Pus bad
How can you tell?
Amount: scant to copious
Too dry cells stick
Too wet cells drown
Northeast Surgical Wound Care
Periwound Edges
Smooth, tightly adherent
Lifting
Rolled
Scar/calloused tissue
White: macerated drowns cells (MASD periwoundwound skin damage)
Northeast Surgical Wound Care
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Periwound with Deep Tissue Injury
Northeast Surgical Wound Care
Periwound Inflammation/Infection
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Wound Bed Granulation Tissue
Northeast Surgical Wound Care
EpithelializationNortheast Surgical Wound Care
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Fibrin Slough
Northeast Surgical Wound Care
Necrotic Tissue/Eschar
Northeast Surgical Wound Care
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Crust/Scab
Northeast Surgical Wound Care
Deep Tissue Injury
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Lets talk about Moisture Associated Skin Damage (MASD) (Not every wound on the BUM is pressure)
Four Types:
1. Incontinence Associated Dermatitis
- Caused by feces/urine
- 37.5% greater chance for PrU
- Pain likened to that of burns
- Many times erroneously called a Stage 2 PU
- Skin split in gluteal cleft?
Inflammation and erosion of skin caused by prolonged exposure to various sources of moisture.
Northeast Surgical Wound Care
MASD: Incontinence Associated Dermatitis
- Treatment of IAD focuses on three main goals:
- Removal of irritants from the affected skin;
- Brief free facility
- Check and Change every hour when using
conservative measures
- Emolllient wipes
- Zinc oxide w/ STNA education
- Eradication of cutaneous infections such as
candidiasis (yeast)
- Do you have a barrier cream w/ miconazole in it?
- Containment or diversion of incontinent urine or stool.
- Foley
- Rectal pouch or fecal Management System
Northeast Surgical Wound Care
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MASD - Intertrigo
Characterized by skin reddening, maceration, burning, itching. Also erosions, fissures, exudation and secondary infections.
Factors predisposed to intertrigoinclude obesity, skin folds, moisture, warmth, sweat retention and friction.
Treatment:
Keep skin folds dry.
Antifungal powders
Powder Prevents, Crme Kills
Intradry Ag (Coloplast)
Wear bras change daily.
Pillow cases, towels and sheets are not recommended as they do not wick fluid away.
Northeast Surgical Wound Care
Inflammation of two skin surfaces that are in constant contact caused by friction and sweat.
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MASD Peristomal Moisture Associated Damage
Causes: stool, urine, perspiration, immersion with baths
Obesity increases risk
Liquid stool has higher level of enzymes
Ileostomy
Colostomy with diarrhea
Pouch Failure catastrophic
Tx:
Wear not to exceed 4 days
Cut to fit barrier, may need belt
Polymer acrylate liquid skin protectant, i.e Marathon by Medline)
Northeast Surgical Wound Care
Inflammation and skin erosion related to moisture that begins at stoma/skin juncture and can extend outward in a 4 in radius.
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MASD Periwound Moisture Associated Damage
Overhydrated skin (maceration) delays healing, increases infection risk, increases friction risk and enlarges the wound.
It prevents cell migration over the wound bed.
Tx:
Liquid acrylates (Marathon by Medline)
Zinc oxide
Absorptive dressings
NPWT
Compression
Northeast Surgical Wound Care
Wound exudate caused by normal inflammatory process of wound healing.
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Wound Documentation
CMS in F-Tag 314 lists the following: Weekly
Date assessed Location Exudate:
Color Type Odor Amount
Recommended to DO IT FOR ALL WOUNDS.
Northeast Surgical Wound Care
Does your documentation meet the
standard for all wounds? F-Tag 309 Quality of Care
Non-pressure related wounds If they are not healing what are you doing about it?
Keep track of all skin issues and have MD/NP/PA determine and document etiology.
CMS is OK with photos if there is a policy.
Etiology must be done or confirmed by a provider who can make a diagnosis (MD, NP, PA) Staging may be done by an RN or LPN after diagnosis. Is Skin Tear a diagnosis? YES Is denudement a diagnosis? NO Is excoriation a diagnosis? NO
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SAMPLE DOCUMENTATION
4/28/2010 9:30AMContacted by STNA of discolored
areas found on bottom of both
feet during shower. Right great
toe has blood blister 1.9 cm x
1.2 cm x 0. Left great toe has
blood blister 2.4 cm x1.6 cm x 0.
No drainage from either blister.
R does not know how
happened. I.M. Grate CNP
notified and treatment
orderedR.U. Appy LPN
***LPN Appy completes an incident report per facility policy.
Northeast Surgical Wound Care
Clarification of Orders Order does not make sense.
Do not have ordered supplies.
Can not read order.
Do not know how to perform treatment.
Protocols DO NOT supercede a providers orders.
Substitution of treatment orders is not acceptable without clarification.
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Scope of Practice Issues Do not change a providers order:
Call the provider who wrote the order. Read ORC 4723 = Ohio Nurse Practice Act
Know your scope of practice.Scope of practice does not change based on where you practice.
NP/CNS orders are NOT Nursing orders.
DONs do not have regulatory authority to change a licensed providers (MD, DO, DPM, NP, CNS, PA) order without calling the provider.
Northeast Surgical Wound Care
Defensive Documentation Assess wound ASAP after notification.
Record wound assessment, how found, what was done and what provider was informed of new finding.
DO NOT DIAGNOSE!!
Always document when provider visited or was contacted.
Do not write your own orders!!!
Document telephone call to provider when you accept a telephone order.
Provider co-signature will not save you from litigation.
Notify POA of when wounds found.
Minimal weekly documentation until closed.
If no improvement or deterioration, notify provider immediately.
If provider fails to respond, notify PCP, Medical Director, DON and Administrator.
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Wound Treatments
Blisters
Do not Pop
Do not Aspirate
They are biological bandaids.
Pad and Protect
Spider Bite>>>>>>>>
Northeast Surgical Wound Care
Keeping Certain Wounds Dry
Protect with Silicon dressings or non-adherent
No tape: not even
paper on the elderly
Abd pads with gauze, abdominal binder or stockinette
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Say NO to moisture Keep Dry No Debridement
Lower Extremity Below the knee Dry, adherent
eschar AHCPR
Guidelines, 1994
Exception: documented
arterial sufficiency or
Eschar starts to drain or
Periwoundcellulitis
Northeast Surgical Wound Care
What to do with dry wounds?
Pad and Protect
Thick WHITE sock Colored hides drainage
ABD pad and gauze wrap
Check for moisture
Alginate or 2x2s btnkissing toes.
Mummification is not so bad!!
Wet gangrene is
Urgent surgical consult
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Wet Gangrene = Wound Emergency
Epidermal lifting
Swelling
Drainage
Erythema
Wet gangrene with Osteomyelitis
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Prevention Tips
Specialty Mattresses Breathable pads
No motherpads
No doubling
No towels
No washcloths
No briefs few exceptions Briefs cause dermatitis
Overlays increase risk for falls
Northeast Surgical Wound Care
Prevention Tips
Reposition correctly Use foam wedges
Not pillows for body
Factoid: Heels show hyperemia at 30 minutes with unrelieved pressure. Need to reposition
frequently
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Prevention Tips
Socks
Thick and white
Prevents friction, shear
Keeps warm
Induces sleep
Heel protectors
No better than socks
Do not prevent pressure
Do not protect toes
Keep wounds covered
Wounds stop healing when less than body temp
Northeast Surgical Wound Care
Prevention Tips
Foley or Tube Pressure Ulcer
AVOIDABLE
Securement Devices
Bard
Stat Lock
PEG/PEJ and Suprapubic
Secure devices to decrease hypergranulation
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MDS Section M
Need accurate data and etiologies
Questions:
Are blisters, sDTI and eschar open or closed? If closed, are they healed?
Can you use the NPUAP guidelines to code the MDS?
Is sDTI a stage 1 or unstageable?
Stage 2 heel ulcer is POA. Two weeks later it is covered with escharand now unstageable. Is it still POA?
Stage 3 coccyx is inhouse/faciltyacquired. Goes to hospital and returns as unstageable. Is it POA?
Northeast Surgical Wound Care
More Section M Questions to Ponder New admission with POA wound to sacrum. History reports Stage 4
ulcer but wound looks like a Stage 3. What do you classify the wound as?
If depth of wound can be measured but the wound bed is partially covered with slough or eschar, is this wound coded as unstageable?
Is a blood blister a stage 2 or sDTI according to Section M? There are two pressure ulcers on the right hip separated by 0.4 cm.
Do you count them as one or two wounds? Stage 3 PU to right heel closes btn MDS assessments and then
reopens three weeks later. Do you record closed wound and new wound?
If a diabetic develop a a pressure ulcer on the heel is it a pressure ulcer or a diabetic foot ulcer?
Are skin tears recorded in the MDS assessment? The treatment for an ulcer is a bandaid. Can I code this in section
M1200G as an application of a non-surgical dressing?
Northeast Surgical Wound Care
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OOPSOUT of TIME Who has questions?
Northeast Surgical Wound Care
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